I feel guilty as I write this. You see, I’m home with my family, safe and warm. Protected. Others, my comrades and fellow nurses are not. But I can guess, and have read and been informed of what they are facing on the front lines: reassigned to new hospitals and new duties, rendering care, sometimes coerced by employers, without adequate protective equipment. No masks. No gowns. No testing to know who is indeed positive for the virus. One of my students wrote to me, expressing her ethical dilemma of whether to care for patients while she went unprotected, potentially cross-pollinating other patients and her family. They – her employers – had reminded her that she has ethically pledged to do so. Her note brought it to a personal level to me. What could she do, she asked me? I advised her to document, to bring others into the demands of adequate protection, and to consult the CDC guidelines, contact her county health department and so forth. I felt my advice was not nearly enough, a defective response to an impossible riddle.
We are in a pandemic, a global disaster, if you will. The United Nations Office of Disaster Risk Reduction: International Strategy for Disaster Reduction (2017) defines disaster as:
A serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. Annotations: The effect of the disaster can be immediate and localized, but is often widespread and could last for a long period of time. The effect may test or exceed the capacity of a community or society to cope using its own resources, and therefore may require assistance from external sources, which could include neighbouring jurisdictions, or those at the national or international levels (n.p.).
That about sums it up, doesn’t it? But what of the nurses’ psychological trauma experienced in the disaster?
My student described insufficient resource trauma, the lack of tangible and intangible resources necessary to render safe and quality care. The resources include knowledge, supplies, nursing staff, and other professionals.
My Middle Range Theory of Psychological Trauma includes this type of psychological trauma and the trauma experienced by being a social actor in the midst of an unfolding disaster (see Figure). Nurses will surely face secondary/vicarious trauma as they witness patients’ suffering and offer comfort and caring. They may participate in system or medically-induced trauma as patients are placed on ventilators, relinquishing control of their bodies. For some patients who lived through the Great Depression, memories of austere times may be invoked, causing anxiety and reflective of historical trauma.
Physicians are often tasked with triaging during disasters as the resources become more strained. But I have met with nurses who were involved in the California fires not too long ago. They felt forgotten and overlooked when the post-fire debriefings took place, as if their place in the healthcare hierarchy removed them from sitting at the healing table.
Another graduate nursing student emailed me about her class assignment. She probably won’t be able to finish it because of all the activities she is being called to do in her hospital, an ever changing world filled with chaos and uncertainty. When I weigh the final paper with saving lives, is there any doubt about what priority I should endorse? But this is territory I’m unfamiliar with.
What I can do is remind myself that my world should be revised, amended, and my teaching should be trauma-informed. I should lace my work with compassion and an understanding of the overwhelming need for people to feel safe, their voices to be heard, and their recovery to be purposeful and inclusive. I can give names to the trauma they are exposed to and by doing so, offer them a path to express this psychological injury now and in the future so that recovery can unfold.
References
Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, IN: Sigma.
United Nations Office of Disaster Risk Reduction. (2017). Terminology. Retrieved from: https://www.unisdr.org/we/inform/terminology.
Dr. Foli – thank you for your post. You bring up many points that I’m sure we’re all feeling as the Covid pandemic unfolds. I was especially appreciative of the points made in your last paragraph – using compassion-based, trauma-informed processes for reframing how we practice nursing as a means to reduce the suffering of others. That was spot-on.
To you and all the other educators who read this, please know that your actions role modeling caring and compassion during a time of grave suffering are SO important (i.e.: weighing appraisal of school work in context of what is going on in the world, being an open-door for students to come with concerns – like your student with the ethical dilemma regarding the PPE). Don’t underestimate the importance of providing and maintaining a safe and compassionate space of consistency for your students. As a student, myself (hopefully, not for much longer – my dissertation defense is scheduled for 5/8!), I can assure you that having faculty maintain even the slightest semblance of normalcy during such uncertain times has truly helped me reign in the omnipresent sense of anxiety that accompanies being a learner during such times (and let’s be honest – just being a student/ learner, in general!). The Buddha taught that the existence of everything is because the existence of everything else – as such, “interbeing” with your students with compassion will reduce their suffering (Georges, 2014, 2013). That compassion will then extend to the care your students provide to their patients, how they interact with their families, how they are as members of their communities, and so on. (And I think this is true for ALL nurses – we ALL have vital roles to play right now – as caregivers, peacemakers, advocates… don’t underestimate the magnitude and ripple effect that can occur from a small act of compassion – especially now – but always).
An on a separate note – your middle-range theory provides an excellent exemplar for a couple points I was making with my recent post regarding how educators approach teaching nursing theory. First, your theory highlights how important it is to teach to what is current, relevant, and contextual to what is going on in the world. I’d be interested to see what happens/ how students would respond if the Middle Range Theory of Psychological Trauma: Healing & Recovery was taught in theory classes this coming fall. I guarantee that students will be able to wrap their heads around it! To that point, and second, I think this makes the case for the importance of middle-range theories both operationally in nursing practice, and in nursing education.
Anyway – just a few thoughts… back to dissertation-writing!
Take care, be safe, and stay healthy,
Shannon
Thank you, Shannon. Such a thoughtful and helpful response. Another student emailed me; she will have to take an incomplete. When she described what she was going through as a direct care provider. I told her — don’t stress about this. I will support you. And I meant it. Take care and thank you again!